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144 Jones Farm RdDAVIE COUNTY ENVIRONMENTAL HEALTH 71q P.O. Box 848/210 Hospital Street I Mocksville, NC 27028 (336)751-8760 Fax #. (336)751-8786 OPERATION PERMIT Account #: 990004349 Tax PIN/EH #: 5778-09-4336.02 Billed To: Mark Jones Subdivision Info: Jones Estate Lot # 2 Reference Name: Location/Address: Indian Hills Drive -27006 Proposed Facility: Residence Property Size: 2.265 acres ATC Number: 4679 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. '�'U � �� Q System Type: _ S.T. Manufacturer6 ,d Tank Date Tank Size�� Pump Tank Size System Installed By: W l E.H. Specialist: `Y L Date: 1 F yS i 1 �3 1 1 v , �I DCHD 11/06 (Revised) 0 r t DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004349 Billed To: Mark Jones Reference Name: Proposed Facility: Residence ATC Number: 4679 Tax PIN/EH #: 5778-09-4336.02 Subdivision Info: Jones Estate Lot # 2 Location/Address: Indian Hills Drive -27006 Property Size: 2.265 acres Site Type: E ew ❑Repair ❑Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use chanee.' Residential Specifications: # Bedrooms J # Bathrooms a # People Basement❑ Basement plumbing❑ Non=Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size a .-I Type of Water Supply: R ounty/City ❑ Well ❑Community Well System Specifications: Design Wastewater Flow (GPD)3(&C> Tank Sized GAL. Pump Tank —AAGAL. Trench Width 3 V ts Max. Trench Depth 36Rock Depth6. Linear Ft. Y 3 tP As stated in 15A NCAC 18A.1969(5� Site Modifications/Conditions/Other: erAe�,ate;, may alee be usP Contact the Davie County Environmental Health Section for final inspection of this system between R:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. Environmental Health Specialist/iy!/��j�Z Date: DCHD 11/06 (Revised) ..o a� C .r- O r l I Environmental Health Specialist/iy!/��j�Z Date: DCHD 11/06 (Revised) tE�MAY 15 2007 LApplica_tii— T7p� Eva T�~D�JI-E��G?1.�libn: ❑New `FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 tion/Improvement Permit To Construct (ATC) ❑ Both stem ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed M,44)%C J n e s Contact Person k- Billing Address�y�y T .� t s r ;� r-,.• �j, Home Phone 373t, 3 qS_,9 &_f 1 City/State/ZIP 4yL/A,.,,s- Al -e- 2-260,6 Business Phone 3'34 Y01? -691:9 Name on Permit/ATC if Different than Above A P /L- _FC n I S Mailing Address City/State/Zip rKUrr-K l Y 11Nr UK1V1A 11U1N 'rDate House/.Facility Corners NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name /11 t4 P %C ,j b y, e- S Phone Number Owner's Address J y q To r, P -S a Y►- C n City/State/Zip /t'�y� rV • G • Z 7 © � Property Address/ Z�/- I- r\ City �J vc, n �-C- Lot Size Tax PIN# f 77 9 Subdivision Name(if applicable) Section/Lot# .� Directions To Site f F_ Ae i' For^ J 64v -1-e('1 A dk - lzf -1 If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes ETNo Does the site contain jurisdictional wetlands? ❑Yes [?No Are there any easements or right-of-ways on the site? ❑ Yes 9No Is the site subject to approval by another public agency? ❑Yes gflo Will wastewater other than domestic sewage be generated? ❑Yes Z�To IF RESIDENCE FILL OUT THE BOX BELOW # People — i # Bedrooms _— # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes [;?No Basement Plumbing: ❑Yes E;�No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested; 2(�onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: VrCounty/City Water ❑.New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? C�To This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or staking the house/facility location, proposed well location and the location of any other amenities. ,0 , i Property owner's or o legal representative signature Site Revisit Charge S -IS - o'7 Date Date(s). Client Notification Date: EHS: Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # -3 5 34'11'011 "E -4 N 86051'53"W -5 N 85052'41 "W -6 S 87047'52"W -7 N 89038'17"W I -1 0 3.135 Acres +/- e Denotes Nonmonumented Points Defining Center Line of Proposed 30' Access Easement `� IRS L-12 ti Shed �oX-o_ d r1 House U)1 i 820 . 1T IRS1L 3 Total (279.56') T -Bar w/cap v Fnd in Line f� t V1 TWINPORT N: 241065.627 m E: 478471.139 m ? CF: 0.99990535 i SO 1 •y i1 RRS Fnd 0 CL +\- �w 2.037 Acres aE_3�__ y _ 646„ L-1 -Total d' + -�-I-' PropuseV i House �,'/ r 2.265 Acres+/- Ui�, Shed 7 ``r ON a Building � —E-6- - �E-5 - Garage s _ Grovel Orlve - - - --_ - - - -__ -_ --_-_ __---•-_ _--_ � � _- ` �� \ L-4 Gravel/Dirt Farts Road IRS L-3 - IRS` ---L-2 Total i • (260.50') T -Bar w/cap o Fnd in Line 0 Tax Lot 55 Tax Map 1-7 y �J n/f Danny Burt Walser c f �- 820 RRS Fnd ® CL +\- r -T-5 - RRS Fnd ® CL +\- Indian Hills Road- S.R. 1613 60' Public R/W 20'+/- Pavement 131.51' Tie Line 820.01' E-3 S 04°24'17"W 314.47' 416.22' E-4 S 89°37'58"E 151.94' 25.16' E-5 S 02°10'45"E 317.10' 42.44' E-6 S 02°10'45"E 458.39' 164.93' E-7 S 02°10'45"E 393.00' E-8 S 89039'46"E 15.01' Tie Line E-9 N 89039'46"W 285.14' Tie Line e Denotes Nonmonumented Points Defining Center Line of Proposed 30' Access Easement `� IRS L-12 ti Shed �oX-o_ d r1 House U)1 i 820 . 1T IRS1L 3 Total (279.56') T -Bar w/cap v Fnd in Line f� t V1 TWINPORT N: 241065.627 m E: 478471.139 m ? CF: 0.99990535 i SO 1 •y i1 RRS Fnd 0 CL +\- �w 2.037 Acres aE_3�__ y _ 646„ L-1 -Total d' + -�-I-' PropuseV i House �,'/ r 2.265 Acres+/- Ui�, Shed 7 ``r ON a Building � —E-6- - �E-5 - Garage s _ Grovel Orlve - - - --_ - - - -__ -_ --_-_ __---•-_ _--_ � � _- ` �� \ L-4 Gravel/Dirt Farts Road IRS L-3 - IRS` ---L-2 Total i • (260.50') T -Bar w/cap o Fnd in Line 0 Tax Lot 55 Tax Map 1-7 y �J n/f Danny Burt Walser c f �- 820 RRS Fnd ® CL +\- r -T-5 - RRS Fnd ® CL +\- Indian Hills Road- S.R. 1613 60' Public R/W 20'+/- Pavement F D1' ITE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Health Department OCT 1 3 2006 Environmental Health Section P.O. Box 848/210 Hospital Street 1 UMROMMFNi NTY Mocksville, NC 27028 pp'v�ECouNn (336)751-8760/ Fax (336)751-8786 Application For: Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed Cruz► Contact Person Billing Address - ' ' , � Home Phone 33 E 0 Ci /State/ZIP h' n 1 Business Phone -336 Name on Permit/ATC ifDifferent than Above Mailing Address PROPERTY INFORMATION NOTE: A survey'plat or site plan must accompany this application. (Permit is�,vlid for 60 months with site plan, no expiration wit c mplete plat.) Street Address -lNcr r1nJ,/�s, City f I IC�I/Q�C%F_ Tax PIN# 9%rj 61 Subdivision Name Sectio ot# Lot Size Directions/To Site: /n .D / i?!' _ it IJ - L,t".0"1 ; / Date House/Facility Corners Flagged 119-13-06 A/Il p Abod6hJe If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes QNo Does the site contain jurisdictional wetlands? ❑Yes EfN' o Are there any easements or right-of-ways on the site? ❑ Yes C-fNo Is the site subject to approval by another public agency? El Yes ENo Will wastewater othet than domestic sewage be generated? ❑Yes 2No IF KESIDENCE FILL OUT THE BOX BELOW # People 2, # Bedrooms# Bathrooms - Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes C11 o Basement Plumbing: ❑Yes (A do IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: �eonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 2150unty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes CSI ---- If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections determine com liance with applicable laws and rules on the above described property located in Davie County and owned by to (j �tl,I �/ ,� Prop rty owner's or owner's lega r presentative signature �1 -I3 ..- CAo ate Sign given n - es ❑No Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # Invoice # �c z X50 -�����€ � � .5 nP itLt.dk4tt5',:.' � �� - � �+�^� � s�'',T • 1115 J —77 S 3 24, Kf eat INDIAN LLS RD #()/d r AMP -ram w S vr� a' r F All "' rr 4 an� s f..s;;,�c:� •. "�'��' ,:�''x gPw "��'' '2k� - :�a n y � �' +.� is 01 Ls we , V. �c ^!W ° r nsr,�� joyr +�.� 4' '`� as s :l 4 z 7} i ' t.� q* � : _ <pR,.r xV fN ON Ivivo t s '� a"gT"k°'- � V e ;,R`rx r,#4�' 'a e i.k`,w :'�✓x` w rte` a¢ ' s � ff r .. K v� sF k x _ � i a��'` `�, '�'fi'✓.^.i .se .. -. ,. ,r+"" � m, ri .y.. ��y:' � ,�„t"..i' •" � � �u,:>..+.. w`c.�*:, .,..1 -:s_'. _,. �e'e°' ..'�• cr,,'�_.r'W,•",�"'"'' - _/ .ae.. `.0 :`..t .,dae�m"-',sb'`` � �_' ?W'� '..-." APPLICANT INFORMATION Account #: 990004142 Billed To: Ronald Jones Reference Name: Proposed Facility: Residence Water Supply: On -Site Well Evaluation By: Auger Boring DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5778-09-4336.02 Subdivision Info: Jones Estate Lot # 2 Location/Address: Indian Hills Drive -27006 Property Size: see map Date Evaluated: `D 0 CommunityV Public Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % b HORIZON I DEPTH Texture group Consistence s=/ Structure Mineralogy HORIZON H DEPTH << > Texture group Consistence Structure /1 Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS 4/10 RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: EVALUATION BY: OTHER(S) PRESENT: REMARKS: LEGEND Landseape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope - CC Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope Texture S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt SICL - Silty clay loam SIL - Silty loam CL - Clay loam . SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C -,Clay CONSISTENCE lYlQist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS Very Sticky NP = Non plastic SP -,Slightly plastic P.- Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crumb GR -Granular . ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed 1YoteS Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil. wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■■s■■■■ecce■■■■■■■ee■■■ecce■■■■■ ■■■■■■■■■■■■■ell■■■■■■■■■■■■■■■■■■■■■■■■■I■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■ell■■■■■■■■■■■■■■■■■�■■■■■■I■■■■■■■■■■■■■■■eee■■■■■■■■ ■■■■■■■■■■■!■Illi■■■■■■■■■■I'======��■■■■■■I■■■■■■■■■■■■■■■■■■■■■■■■■■ MEMO MEN ■■■Lff%■'11■■■■■ MEMO ■II■■■■■■■■c■c■■■le■■v'ArfArA®■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■sal■■■■■■■■■■■■■■r:�a■■■■se■e■I■c■■■■■■■■■■■■■■■■■■■■■■■■ iiiiiiiisiiiiiiiaii MEMNO iMEMNONMEMNONiiiiii ■■■■■■■c■■■■■■■■■■■■■■■■YID%�■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■emcee■■■■■■c■e■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Improvement Permit October 20, 2006 Ronald G. Jones 168 Cedar Hill Lane Advance, NC 27006 Re: Indian Hills Jones Estate: 5778094336.02 Dear Mr. Jones, This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. System To Serve: ^ SWaste ater Design Flow(GPD):-;�w6U Valid: Kyears ❑No Expiration System Type: ❑Conventional Accepted ❑Innovative ❑Alternative ❑Other Site Modifications/Permit Conditions: As stated in 15A NCAC 18A.5.9-69(5) accepted Systems may also bct used i.p.letter 1/06 r 13ALK